Sex is a very intimate and important aspect of human life. The problem of sexual inadequacy is very common. About 10% of the world’s population suffers from it. Most people do not know where to go and with whom to discuss their sex problems. Sexuality is a large component of one’s personality, going far beyond merely the physical organs of the body. Some of the important causes of sexual inadequacies and their treatments are discussed in this section. The most important causes of sexual inadequacies are impotence (erectile dysfunction), premature ejaculation, and diminished sexual desire (libido). There has been a major breakthrough in the treatment of erectile dysfunction but far more research is needed to deal successfully with other sexual disorders.
Erectile Dysfunction (Impotence)
Erectile dysfunction is another name for impotence or the inability to achieve a sexual erection or orgasm.
Causes: In general, it effects 1 in 20 men from the ages of 40 years and above and about 1 in 2 over the age of 65 years. There are four types of disorders associated with impotence. These are: 1) Diseases of blood vessels supplying penis; 2) Diseases of nerves of penis; 3) Use of certain drugs; and 4) Psychological causes (most common).
Narrowing of penile blood vessels can occur due to advanced diabetes mellitus and atherosclerosis. Diabetes can also damages the nerves. Certain diseases of backbone, long use of alcohal and stroke can also lead to impotence due to nerve damage. Some drugs such as thiazidas, antidepressants, cimetidine, antipsychotic agents are also known to cause impotence in adults. Low testosterone level is an uncommon cause of impotence. In young men psychological disturbances is the main cause. Myths and false concepts about sex and anxiety about sexual relationships are some of the reasons for erectile dysfunction.
Sildenafil ( Penegra, Erix, Androz, 11 PM)
The discovery of sildenafil is a major breakthrough in the treatment of erectile dysfunction. The drug’s ‘potency’ enhancing effect was observed by chance in 1990. Before that it was investigated for the treatment of chest pain (angina), it did nothing at all to relieve anginal pain.
How Does Sildenafil Act? It acts only on the erectile tissue of the penis. It increase the supply of blood in the organ, causing a hydraulic action. It enhances the physiological response to sexual arousal, causing penile erection. The chemical nitric oxide released from nerve endings and blood vessels in response to sexual arousal, increases production of another chemical- cyclic guanosine monophosphate (cGMP). This chemical relaxes the smooth muscles of the spongy tissue of the penis, allowing an engorgement due to accumulation of blood. The organ bulges and becomes tight and rigid. The process is reversed by conversion of the active cGMP to an inactive GMP by an enzyme called phosphodiesterase type-5. Sildenafil inhibits this enzyme and allows the cGMP to accumulate in order to sustain the pooling of blood and the erection.
In most cases, though the penis becomes rigid, the erection achieved may not be as that of a normal person. Sometimes the drug has very little effect or even fail to respond. In general, it works in 70% men with erectile dysfunction. The outcome may not be as good in those who drink alcohol and in smokers, and those; who eat fatty meals. Eating a fatty meal before taking the drug, hinders its absorption. There is also no evidence of it’s action on women though there are some claims that it increases the blood circulation in the pelvic region, clitoris and may cause sexual arousal. Scientific studies have clearly shown that it does not affect sexual desire (libido). It is effective in men with diabetes, hepatitis, and multiple sclerosis, in spinal injuries, as well as in about 30 to 40% of men whose prostate has been removed.
Dosage: It is available as 25, 50, and 100 mg tablets. The starting dose is 50 mg per day. The maximum recommended dose is 100 mg. If the erection is more than satisfactory, the dose should be reduced to 25 mg. It takes about half to one hour to act and the effect may last for 4 to 6 hours.
Adverse Effects: Sildenafil lowers the blood pressure only slightly in normal persons but substantially in patients who are taking drugs such as nitrates for angina pectoris. Headache, flushing, and dyspepsia are the most common side-effects. Nasal congestion, diarrhoea, dizziness, and rash may occur in rare cases. Transient abnormal vision with a colour tinge (that is, seeing a blue haze), and increased sensitivity to light are uncommon. This adverse effect occurs more frequently with 100 mg than with 50 mg doses. In general, most people do not suffer from any significant adverse effects as the drug is taken infrequently. Moreover the adverse effects have not stopped men from using the drug.
Precautions
- It should never be taken by patients with coronary heart disease, or those who are taking nitrates or those with blood cancer.
- Drugs like cimetidine, erythromycin, and ketoconazole decrease the metabolism and increase its effect.
- Rifampicin increases its metabolism and reduces its effect.
- A doctor must be consulted by those above the age of 65 years, or have any liver or kidney disorders, or they should start with a smaller dose of 25 mg, and increase it only after consulting the doctor.
- It should not be taken more than once a day.
- Alcohol intake may increase drug induced fall in BP.
Tadalafil (Erotid 10mg, 20 mg)
It produces satisfactory erection and has a longer effect. Therefore it can be taken once a day and the sexual performance is successful even upto 24 hours. The adverse effects of sildenafil are the less often seen with this drug. However same precautions need to be observed. Read more on chewable Sildenafil and Tadalafil.
Direct Injections of Drug into Penis before Sexual Intercourse
Injection of papaverine and phentolamine (PIPE treatment) into the body of penis by a tuberculin syringe produces erection to permit sexual intercourse. There are problem of longer lasting and painful erection (priapism) and repeated injections cause damage to penis (fibrosis and infections).
Prostaglandin (Alprostadil)
Prostaglandin in the form of urethral suppository can be inserted into urinary passage of penis before sexual intercourse but it may cause irritation and burning sensation.
Penile Devices
Implants are available which can be placed into penis in such a way that before sexual intercourse they can be inflated (by air) to make penis rigid.
A vacuum constriction device (cylinder) is also available that draws the penis into erected state when suction is applied to create vacuum. When erect, a rubber band is applied over penis base to keep it in that stage for vaginal introduction. The cylinder is removed before intercourse.
Surgery Over Penis
If blood vessels are narrowed or blocked, an arterial bypass (akin to heart bypass) surgery is done to allow blood flow into penis. This surgery is rarely undertaken and that too in suitable cases only.
Herbal Preparations
A number of licensed herbal preparations are available in market. These are recommended for a variety of sexual inadequacies. Examples are Himcolin Gel, to be applied locally over penis, Tentex Royal, to be taken an hour before sexual intercourse. Their utility is doubtful.
Premature Ejaculation
This is one of the most common causes of sexual inadequacy in men. Reaching a climax before one wants to, is described as a ‘premature ejaculation’. In other words, it is an early orgasmic response. It is mainly a problem of adolescent boys.
The causes may be primary- wherein the disorder exists from the beginning, or secondary- wherein it occurs subsequent to a prior normal function. The causes and mechanism are:
Some exercises are prescribed to improve orgasmic control. These help an individual to develop control gradually and progressively. A qualified sexologist should be consulted for the programme of exercises. Other measures include:
- Voluntarily interrupting and restarting the flow of urine repeatedly (to exercise the pubococcygeus muscle).
- Taking a deep breath and voluntarily contracting the anal sphincter (a ring of muscle surrounding and guarding or closing the anus), holding the contraction for 15 to 20 seconds, and then releasing it. This may be repeated up to 20 times, twice a day.
- The squeeze technique: voluntarily, the partner squeezes the penis just prior to reaching orgasm.
- Wearing a condom to decrease sensitivity.
- Drugs to delay ejaculation.
Some local anaesthetics are prescribed to prevent premature ejaculation. They are: Lignocaine 5% ointment, 2% gelly.
Lignocaine is generally considered to be safe and effective. When applied around the penis, it decrease sensitivity and delays ejaculation. There may be some initial irritation which is followed by a decreased sensation. A small amount is applied 15 to 20 minutes before and may be washed off before sexual act.
Adverse Effects: Any adverse effects are dose-related. These anaesthetics may cause allergic reactions such as burning, stinging, and tenderness. In rare cases, there may be very delayed orgasms or even failure of ejaculation due to numbness.
Herbal drugs like CONFIDO and others have uncertain value in premature ejaculation.
Diminished Sexual Desire (Loss of Libido)
Several substances, including foods and drugs, have been used to treat impotence or to stimulate sexual desire. These agents are called sex tonics or aphrodisiacs, a name derived from Aphrodite, the Greek goddess of love. To understand the mechanism of action of these aphrodisiacs, we must first understand the mechanics of sexual response in man and woman. There is a sex centre in the brain which can be stimulated by external stimuli such as sight, odour, touch, and sound. An aphrodisiac may work by stimulating the sex centre in the brain or by causing local irritation and increasing the flow of blood in the genital organs.
Causes: It is commonly due to a traumatic experience in past, boredom in relationship and (monotony), hormonal decline and use of drugs such as sedatives, antidepressants, prazosin and other BP lowering drugs.
While many therapies have been tried to improve sex drive, but counselling and behaviour therapy helps a lot. Various substances which have been used for this purpose are described below:
Foods: It is said that a high-protein diet may increase sexual desire. Various foods such as eggs, meat, crabs, oysters, and caviar are supposed to have an aphrodisiac action. The truth of this belief has so far, not been ascertained. However, the psychological aspect appears to be an importent factor in their perceived effect.
Alcohol: The effect of alcohol on sexual desire is discussed in detail in the chapter on ‘ Alcohol’. It causes generalized stimulation by removing the inhibitions which keep a check on behaviour. Alcohol is consumed before intercourse with the idea that it will enhance potency. In his famous drama, Macbeth, Shakespeare wrote, ‘Alcohol provokes the desire but takes away the performance’. The chronic intake of alcohol may lead to a permanent impairment of sexual functions.
Spanish Fly (Cantharadin)
Spanish fly also sold under the name of Cantharadin was originally prepared from a small (Spanish) beetle named Canthans veslcatona. Its synthetic preparation is now available too. A few drops of this drug are mixed in a beverage and taken. It passes unchanged into the urine, causing severe irritation and inflammation of the bladder and urethra (urinary tract), and dilating the blood vessels. This stimulates the genitals.
The margin between the effective dose and the lethal dose of this drug is very narrow. A slightly higher dose may cause severe abdominal pain and painful urination, and destroy the mucous membrane of the urinary bladder and the urethra.
Testosterone (Testanon, Aquaviron)
Testosterone (the male sex hormone) is often used for an aphrodisiac effect. It is rarely effective except in cases where there is a deficiency of this hormone such is an old age, in the absence of the testes, and in the non-appearance of secondary sexual characteristics in males. In most developed countries, this is not used in the routine treatment of sexual dysfunctions even in ageing males owing to the risk of adverse effects. Unless one is sure of the decreased level of the hormone, it should not be administered. An external dose of testosterone may derange the liver functions and lead to jaundice. It may cause enlargement of the prostate gland, causing difficulty In passing urine. Prolonged use may also cause cancer of the liver or the prostate.
Precautions
- It should not be given unless the deficiency has been established, as the aphrodisiac effect is doubtful without deficiency of the hormone.
- The liver function should be checked at frequent intervals and if there are any signs of jaundice, the drug should be stopped and the doctor should be consulted.
- If there are any signs of prostatic enlargement, this should not be taken.
- Testosterone should not be taken by women as it may lead to hair growth in unwanted areas and deepen the voice.
- It should not be given to young persons as it may cause decreased functioning of the tests.
- It should nto be administered to a person taking antidepressant drugs becuase of the risk of developing psychtic symptoms.
Cannabis
Cannabis is obtained from the plant Cannabis indica or Cannabis sativa. The leaves of these plants are called bhang; the flowering tops, especially of the female plant, are known as ganja (marijuana); and the resinous exudate as charas (hashish).
Cannabis is more of a depressant of the central nervous system rather than a stimulant causes relaxation, euphoria, increases appetite, and impairs judgement and co-ordination. The overall effect is to remove inhibitions and release more primitive impulses. The assumed aphrodisiac effect of cannabis may be due to an increase in suggestibility or uninhibited behaviour. It has no real aphrodisiac effect.
It causes dryness of the mouth, increases thirst, reddens the eyes, increases the pulse rate, and may even cause fear, panic, and agitation.
Cocaine
Cocaine was once used for sexual stimulation. It may cause constipation, loss of appetite and impotence. It is habit- forming. Larger doses may cause auditory an visual hallucinations and other psychotic symptoms. The use of this drug is not advisable.
Musk
This is a viscid substance with a pungent odour, found in a sac under the abdomen of the male Asiatic deer. It is believed that if the substance is rubbed on the penis, it will cause an aphrodisiac effect. However, no evidence of the same is available in human beings.
